Mirizzi syndrome: noteworthy aspects of a retrospective study in one centre

Mirizzi syndrome is uncommon. It is, however, clinically important, as it is associated with an increased incidence of bile duct injury and demands more complex surgical techniques.

A retrospective review of 24 consecutive cases of Mirizzi syndrome that arose between January 1997 and July 2002 was performed. A total of 1881 cholecystectomies were performed during that period.

Of the 24 patients, 19 (79.2%) had Mirizzi type I, four (16.7%) had type II, while one (4.2%) had type III disease. Only 54.2% of patients were symptomatic prior to presentation. One-third of patients had normal liver function tests. Ultrasonography and computed tomography were not helpful in diagnosing this entity. Endoscopic retrograde cholangiopancreatography (ERCP) was useful to identify cholecystocholedochal fistulas and to allow therapeutic endoscopic stenting but failed to pick up the syndrome in half of the patients. Inadvertent bile duct injury occurred in four patients (16.7%), all occurred in patients without a preoperative diagnosis. Three of the four injuries occurred during operations by a senior registrar rather than a consultant. Mirizzi type I was managed with either total or subtotal cholecystectomy, while types II and III cases were managed with either T-tube insertion or biliary bypass procedures. Bile duct injury was managed with T-tube successfully in one patient while the rest went on to biliary bypass operations. All except one patient had good functional outcomes on follow up.

The preoperative diagnosis of Mirizzi syndrome is a challenge. Only constant vigilance during intraoperative dissection of the Calot's triangle will reduce the incidence of bile duct injury in Mirizzi syndrome that can occur in both open and laparoscopic surgery.